Awhile back*, I posted about my daughter’s premature birth, hospitalization, my concurrent job loss, and…..health insurance. I tried to explain to non-U.S. readers exactly why the loss of a job meant the loss of healthcare and probable bankruptcy. We take that for granted in the U.S.—that in the event of a serious illness like cancer, in the event that one doesn’t have a spouse, parents, siblings, or a trust fund, that one will probably go bankrupt. That for most of us, serious illness or injury means the loss of a job. And the converse, too—that the loss of a job means crossing one’s fingers and hoping one doesn’t get sick or injured, because one will be left without a means of getting treatment. The two situations go together here like thunderstorms and rain.

So, when the illustrious Lauren of Feministe sent me this link, I wasn’t surprised at the findings. As costs have gone up, the number of uninsured people has risen exponentially. This graphic doesn’t even delve into the problems of rising deductibles (hence, a bigger bite of the paycheck). The 7% cost given for the average Illinois worker with family coverage is I’m assuming the pre-tax income cost—not take-home pay.

Here’s another interesting graphic with a timeline, on job losses and unemployment rates. Notice any similarities to the graphic on health insurance? How about this one on bankruptcies?

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My aunt told me recently that she doesn’t like the “socialized health care plan” because why should she work hard to pay for insurance for the lazy unemployed? I responded that I work very hard and I still don’t have insurance, where does that leave me in your little black and white world? People don’t understand that there is not a direct correlation between “People who work hard” and “People who have money/ benefits” so people assume that folks who are broke and don’t have health insurance must be too lazy to earn. Even when you explain how you work hard at a job with low pay and benefits they tell you that you should just find a new job, like its that easy! Lots of people are in a position between no income and a income with sacrifices in benefits, and companies know this and take advantage of the piddling options.

La Lubu, that link from DailyKos is unbelievable… but of course, SO believable. Happening to a friend of mine right now, more or less exactly the way she describes (slapping high cost on employer, then fired).

There’s a calculus that’s going on in the minds of most insured Americans (the ones I talk to in my white urban professional upper middle class bubble, and the ones represented in plenty of coverage, whether or not reflective of real pluralities) that President Obama tried to speak to in his address to the nation, and it goes something like this (also, most doctors are doing this math from a more educated, and differently interested, position):

There’s X number of doctors in the U.S., and most of them work way beyond 9-5, five days/week. They already currently don’t give enough time to patients as it is. There’s Y number of people who currently have access to medical care. That number Y could as much as double (since most insurance is crummy anyway and people don’t have unlimited access now), but number X is staying right where it is. So the access of people who currently have insurance either has to be reduced, or the quality of the care they receive has to be reduced by longer waits between visits and less time with the doctor. This math doesn’t just have to be applied to doctors; it applies to MRI machines, operating rooms… these are limited resources. Currently, we ration these resources out by giving them to people with better jobs, better healthcare, some combination of the two, or people who have lived past 65, while people who aren’t in those categories die.

The proposal, as far as it’s been explained, is to ration out care on a basis that is blind to all but need. To people who are relatively healthy, with moderate complaints, this sounds like condemning them to discomfort with all but life-threatening illness, as doctors devote all their time to making sure no one dies.

President Obama’s answer to this concern was to imply that people who think they’re in the lucky insured category now will find themselves out of that category within the next couple of decades. But is there another way to suggest to people who work hard at good jobs that they can get a little bit of an edge over mythical welfare queens in getting their healthcare? Is there a way to convince doctors that they will be treating anything beyond life-threatening illness, that they’ll be able to pay attention to quality-of-life issues without bankrupting their offices or working themselves into an early grave? That they’ll have time for research, that their opinions as professionals will still be respected (as they are for patients who have private, non-HMO insurance)? That they’ll be able to pay off their college and medical school and internship/residency debt without having to live on a sofabed in a studio apartment like the drummer in a bad Chicago-area band?

Forget about the tax issues; people who have medical care want to keep getting their medical care. Unless the President’s proposal is to increase the number of nurses/nurse practitioners out there to fill the primary care role, which would have some of the same effects as increasing the numbers of doctors, people who have health care stand to lose quality of treatment if access is democratized… or good health care will be even more expensive than it is now, as all well-regarded medical providers move to a cash-only system and there’s no insurance for less-than-emergency/life-threatening conditions.

And that’s still what’s going to happen if you increase the number of doctors out there, because if you make it easier to be a doctor, you’ll end up with a lot of doctors who are, you know, stupider than the people who are currently doctors. This is also true if you reduce doctor compensation. A lot of people go into medicine for the salary, not the passion– and a lot of those people make great doctors right now, but will go into biotech research, or banking, or law, or something else lucrative instead.

So: Can you create a parallel system that provides basic care to currently uninsured individuals without putting them into the same system as the currently-insured, or without decreasing quality of care for those currently covered? Maybe. And that’s the program that will overcome a lot of the current opposition.

So: Can you create a parallel system that provides basic care to currently uninsured individuals without putting them into the same system as the currently-insured, or without decreasing quality of care for those currently covered? Maybe. And that’s the program that will overcome a lot of the current opposition.

There’s no “maybe” about it, Flash. Every other industrialized nation has this figured out. France. Germany. Japan. Switzerland. Etc. The current opposition has a lot more to do with “how will I know I’m On Top™ if all the plebes can get healthcare, too?”

But these other countries don’t exactly have it figured out, for a variety of reasons. In Germany, doctors’ salaries have the purchasing power of about 20% of what they have in the U.S. On top of that, everyone’s salary is taxed at an additional 10-15%. EVERYONE. You can’t opt out, but you can buy supplemental coverage at high cost if you want… which means that, to get anything above the level of healthcare offered to the general public, you need to pay about two months’ salary every year on healthcare. And then, of course, the doctors aren’t as good (see: salary differential). Finally, in Germany, the tax rate for healthcare is set, and the ‘sickness funds’ have to be self-supporting; if you join a sickness fund and there’s a nuclear meltdown on the other side of the country and the town next to the plant was populated by people in your sickness fund, there’s no money left for your knee replacement.

In France, there’s this: More than 92% of French residents have complementary private insurance. This insurance pays for additional fees in order to access higher quality providers. Private health insurances makes up 12.7% of French health care spending. These complementary private insurance funds are very loosely regulated (less than in the U.S.) and the only stringent requirement is guaranteed renewability. Private insurance benefits are not equally distributed so there is, in essence, a two-tier system… Which is what I was proposing. But can you sell a universal healthcare package that’s, you know, crap? If we make it cheap enough, you’ll be able to just keep everyone on life support, I guess, sort of. We’re bigger than France and have twice as large a portion of the population (France’s 6% to our 12-17%) living below the poverty line and therefore not paying in.

Also, in France, billing and recordkeeping are organized by the government. We don’t have this because of, among other things, privacy concerns; in the 90s, non-centralized and highly-private record keeping became a big deal in the U.S. because people didn’t want their employers to know they had AIDS. Also, people applying for all sorts of insurance policies– not only health, but also life– want these records to be kept secret. So, things are different in France because the costs are spread out among more people and there are systemic differences that make healthcare cheaper. These might be some of what the President is referring to when he talks about limiting inefficiencies in the current system, but he needs to make that clearer. Also, French doctors earn about 40,000 Euros/year, which, even if you turn that into dollars at roughly $80,000, is a lot less than what U.S. doctors make. This is partly okay because French medical school is free, while U.S. medical school is not, so French doctors don’t have 100,000 Euros of debt to pay off. All the same, you lose the support of the U.S. medical community the second you start talking about changing compensation or practices.

Switzerland has, essentially, no poor people. Only 3% of the country relies on government assistance. when everyone works and pays in, it’s easy to have good healthcare, because there’s plenty of money around to provide the right incentives. It’s great to be a doctor in Switzerland. If you can motivate more brilliant people in the U.S. to become doctors by increasing compensation, you can have broader medical coverage. Also, in Switzerland, healthcare is all private; the companies are just prevented by law from making a profit on basic coverage, but still have to compete against each other to get basic coverage customers, so they can convince some of their basic coverage customers to buy the profit-permitted add-on coverages, for things like, uh, dentistry. you can picture how this would play out in the U.S.; the profitable coverages, and the basic coverages, would all put their focus on getting the people who have health insurance now anyway (i.e. people who can buy the add-ons), while people in communities without coverage now would be getting, you know, half-hearted motions in the direction of coverage. this is partly because of how dramatically economically segregated we are in this country.

And then, in Japan, the hospitals are all going bankrupt.

So there’s the reasons why European plans wouldn’t work here the way they do over there. Part of it is BS cultural posturing (why NOT have centralized recordkeeping and take that item off hospitals’ budgets? Privacy seems to be in the same category as those accusations of haughty individualism the Europeans like to throw at us), part of it is economic (i.e. we all know the U.S. is lousy with economic disparity, so there would be a higher percentage of the population not paying in, and a lower percentage paying in), and part of it has to do with the medical profession as it exists in the United States (insurance companies pay for doctors’ education, sort of. Also, we respect our doctors more.).

But what if you expand the ranks of medical schools by 20%, and then create a two-tiered system where the bottom 50% get put into the public insurance system, and the top 50% go into the private insurance system, which would address the issue of doctor quality for people getting private insurance, would expand the resources of the system to accomodate more participants (over time; this would take a decade to really hit), and would keep compensation and quality of care options for medical professionals available to enough of them to make it a real possibility.

which means that, to get anything above the level of healthcare offered to the general public,

and

And then, of course, the doctors aren’t as good

Can you refer me to a link that shows that what is offered as “general public” healthcare is substandard? Or that demonstrates some objective parameter for your assertion that the doctors aren’t as “good”? (not as well educated? not as well trained? poorer patient outcomes than in the U.S.? what?) I ask because the only statistics that I’ve seen are the general ones that reference life expectancy and infant mortality rates, which are better than in the U.S.; that leads me to believe that the physicians must be more than adequate and/or that the way the heathcare system runs is superior.

While you’re right that outcomes in those countries have good statistics, that’s partly because statistics in this country include people who are getting crummy care because they’re not covered by insurance. So if you limited your statistics in the U.s. to people who have decent insurance, you’d probably get a very different comparison.

And, even setting that aside, doctor quality isn’t the only factor influencing outcomes or infant mortality– those are driven by access to care, resources available in the course of care, genetic diversity in the population (we’re much, much more diverse than any of the countries discussed. And if you want to see how genetics drives those statistics, consider the case of Utah, with about the highest life expectancy in the U.S.– it’s not just because Mormons abstain from alcohol. It’s environmental and genetic. Utah is 95% white.), etc. Doctor quality isn’t really an issue until you get to tricky stuff– like how, in that story you linked to about the woman with leukemia, her doctor told her she should, no-way, no-how, go to a local or regional hospital, but had to go to a research hospital. So, a) she had a very good doctor at that moment, and b) he knew the other doctors in his area weren’t good enough.

So the factor that often indicates “quality” when you’re dealing with fields that depend on research and development is frequency of citation. The U.S. leads that in spades, even if you account for population size. You can see total citations for all scientific papers here: http://sciencewatch.com/dr/cou/2009/09janALLPAPRS/

I should add that, of course, there are phenomenal research centers internationally, but in terms of creating a system that encourages multiple fountains from which may spring the continued improvements in life expectancy and quality of life that we see among the insured in the U.S., the U.S. does a much, much better job of encouraging smart, enterprising people to become doctors and deal with our toughest cases. That’s not to say that there aren’t countries that have excelled at specific fields– like opthamology in Cuba– but for systemic medical excellence, you can’t beat the U.S.

Fun background note from a professor of mine in law school who had been a doctor before he became a lawyer: the U.S. *does* take the lead when it comes to looking at care for the well-cared-for. The U.S. is #1 for life expectancy… at age 85. so if you’ve been well-taken-care-of such that you made it to age 85, you obviously have the resources to keep going, beyond what other countries can offer. *that’s* what people don’t want to give up.

In all these discussions, people ignore one major elephant in the room. You cannot compare populations from Europe with US.

Healthcare costs that insurance companies are most scared of are from chronic conditions. Unlike a broken bone, these costs are there for years and usually get worse. A major contributor to chronic conditions is obesity which is far higher in US. Even worse, it is higher in the poorer sections of society which will be added to insurance rolls (public or private) if some of the plans pass and no insurer would like to have them.

They have plenty of fat people in other countries, LeftieLeftist. I’m really tired of the “only Americans are such OMG FATASSES” trope. And have you ever stopped to think that in many cases, our “chronic conditions” (and/or the medications needed to treat them) have caused our weight gain, rather than the other way around? But yeah, they could just gas us all and save bunches of money, I’m sure.

I just don’t see how people can run around swaggering that “WE’RE NUMBER ONE!” and then turn around and say we’re the only industrialized nation on earth that can’t manage to make healthcare available for everyone who needs it. That’s just ridiculous. And yes, there will need to be increases in primary care providers especially, but nurse practitioners can do that job just as well as MDs or DOs, and they can be trained a lot faster, too.

Flash: If you are wondering why it took so long for your comments to show up, it is because I was busy last night at a function at my daughter’s school (“4th and 5th grade math night”) and wasn’t monitoring the comment board. Those who were, probably hesitated to approve your comments given that there were three rapid-fire comments in a row, and your style of argument seems to be to drown out any respondents—a violation of Basic Internet Etiquette 101 on a par WITH SHOUTING.

With that said, you and I are always going to be talking past one another on this issue. You seem to be overly concerned with “ohmigod, I’ll never get to see a doctor if those proletarians are clogging up the waiting room!!111!!!” I don’t see this as a problem, but for those who do, there is already a “solution” in operation: concierge care. You and your wealthy friends merely pay a premium charge to a physician who is on retainer. That physician will then see you, with no fear of having to rub elbows in the waiting room with anyone not of your station. Think of it as belonging to a country club. Meanwhile, with universal care with the public option, mere working people like me won’t be without. I’m working right now, so I have insurance. It’s pretty damn expensive (I’m a union member; it’s a negotiated benefit). The time will soon come when we—the union members and contractors who have formed the self-funded insurance plan—will no longer be able to deal with the high cost of insurance. Then the lion’s share of us will not have insurance. We’ll be planning our funerals in the event of cancer, instead of our regimen of treatment. You can’t host enough spaghetti dinners to cover that cost (though people try—sometimes they get a really good turnout and even clear a thousand dollars!).

I can’t help but notice that the only thing you took away from that story on DKos is the issue of quality of doctors. You completely glossed over the job loss, the common occurrence of firings to save on health insurance, the effect that those things have on the lives of people. That wasn’t an abstract story; a person is connected to that story, and she isn’t the only one.

When I look at our current system of delivery for healthcare, I can’t help but see it as a building that is in the process of falling down. An old, dilapidated building that has cleary seen better days, and still has remnants of beauty and function that are still visible, but whose foundation is badly damaged. It’s only a matter of time. And it doesn’t have to be this way.

And….what Meowser said. A major contributor to the high cost of healthcare here is lack of access to basic healthcare at the beginning stages of a disease or condition, that cause that disease or condition to advance to the point where it is more difficult and expensive to treat. Uninsured people can only receive care at the emergency room, which is more expensive than at a clinic. The question is: do we want a modern society with a modern economy or not? If the answer is “yes”, then we need a public option. If we want a feudal economy, then we just need to let the current course proceed.

One more thing for Flash—where are your statistics for the U.S. being number one in life expectancy? All the graphs I’ve seen show the U.S. as being somewhere between the mid-thirties and low forties among a list of nations. The only consistent statistic I’ve seen on the U.S. is that we spend the most, yet don’t see results consistent with that spending. And Flash? Brevity is a virtue.

sorry for the three comments in a row… When I saw what I’d done, I tried to use the “edit” button to put them together, but that didn’t seem to work.

And I’m not exactly expressing these things myself– I understand the tradeoff of increasing access and decreasing quality of care for the currently insured, and I’m not against it. But the tradeoff is real, and ignoring it is a big barrier to building the political will to getting healthcare reform done.

Anyway, I got the point of the DKos story– which is why I kept making caveats about how you have to have good insurance, first, and people in a charge-the-employer-more-next-year situation… don’t. The system’s grant of access is totally sick, but there are entrenched interests here by more than just insurance companies, and that needs to be acknowledged– that otherwise perfectly decent people will get worse care because of healthcare reform. It might be worth it for you, and for people who have bad insurance or no insurance, or for anyone who feels generous on this subject, but for a lot of those people, it isn’t worth it, especially if they have a chronic condition for which they’ve gotten outstanding care.

Like I said, my datum about life expectancy was from a law school professor… but the stat isn’t just “life expectancy”, it’s “life expectancy for people at age 85″– it’s only the life expectancy for people who have already lived to age 85. you’re right that the U.S. is way behind on other life expectancy lists, in large part because the only people who live to age 85 are people who have good insurance, so they just keep on chugging with their better-than-medicare coverage.